Use of Motivational Interviewing Interventions to Move the Client through the Stages of Change Elizabeth Frei, LCSW Addiction Services Program Coordinator High Focus Centers

“Taking a new step, uttering a new

word, is what people fear most.”

― Fyodor Dostoyevsky, Crime and Punishment

Objectives SACs will be able to…

1. identify the stages of change. 2. describe the spirit of Motivation Interviewing. 3. identify the key principles of Motivational

Interviewing. 4. recognize specific Motivational Interviewing

techniques that can be utilized with students.

Stages of Change • The Transtheoretical Model of Change provides

a framework which allows us to understand and intervene within the change process.

• Each stage: represents a point along a full course of changing is well-defined, predictable, and entails a set of

thoughts and behaviors. Is fluid, with a client moving backwards or forwards

at any point.

Precontemplation

Maintenance Contemplation

Preparation Action

Relapse

Precontemplation • Individual is unaware of the problem behavior or

they are unwilling, or discouraged, when it comes to changing it

• Tasks for this stage: Establishing rapport Exploring the client’s perceptions Raising doubts and expressing concern Keeping the door open

Contemplation

• The individual acknowledges the problem and beings to think about it, but is ambivalent about changing it

• Tasks for this stage: Normalize the ambivalence Weighing pros and cons Emphasize free choice, self-efficacy and autonomy

Preparation

• The individual is planning to make a change in the near future and is committed to doing so, but is still considering what to do.

• Tasks for this stage: Clarify the client’s goal Consider barriers to change Explore treatment expectations and client’s

confidence in making changes

Action

• The individual is actively taking steps to change their behavior. This stage takes the most time and energy commitment

• Tasks for this stage: Engage the client in treatment Acknowledge difficulties Help the client assess family/social supports

Maintenance

• The individual achieved initial goals and is working on maintaining goals and preventing relapse

• Tasks for this stage: Support lifestyle change Maintain supportive contact Affirm the client’s resolve and self-efficacy

Relapse

• A recurrence of symptoms which can occur at any time.

• Tasks for this stage: Assist the individual with reentering the change

cycle Exploring the meaning of the recurrence as a

learning opportunity

What is Motivational Interviewing (MI)?

“It is not something that one does to people; rather, it is fundamentally a way of being with and for

people – a facilitative approach to communication that evokes natural changes.”

(Miller & Rollnick, 2002)

What is Motivational Interviewing (MI)?

• William R. Miller and Stephen Rollnick, founders of MI, define it as “a client-centered, reactive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” Focus is on the concerns and perspectives of the

individual and eliciting the person’s intrinsic motivation to change

There is an intentional focus on resolving ambivalence Cannot be used to impose change that is inconsistent

with the person’s own values and beliefs (Miller & Rollnick, 2002)

The Spirit of Motivational Interviewing

“The word that allows yes, the word that makes no possible. The word that puts the free in freedom and takes the obligation out of love. The word that throws a window open after the final door is closed. The word upon which

all adventure, all exhilaration, all meaning, all honor depends. The word that fires evolution’s motor of mud.

The word that the cocoon whispers to the caterpillar. The word that molecules recite before bonding. The word that separates that which is dead from that which is living. The

word no mirror can turn around. CHOICE.” -Tom Robbins, Still Life with Woodpecker

Autonomy • One person cannot make another person change.

Motivation for change lies within the client and so there must be respect for the client’s autonomy One can provide an environment of “supportive

autonomy” by seeking the client’s perspective, providing a menu of options, and emphasizing their personal choice and responsibility (Naar-King, 2011)

Collaboration • The spirit is collaborative, meaning the relationships

should be partnership-like • The stance is support over persuasion or argument • The clinician seeks to create a positive interpersonal

atmosphere

Evocation

• Takes a tone of eliciting and drawing out things from the client rather than the imparting wisdom or advice.

• The goal is to draw on the client’s own perceptions, goals and values rather than seeking to address deficits in knowledge, insight or skills

Motivational Interviewing is NOT…

• Authoritarian or expert in stance • Argumentative • When the clinician does most of the talking • Coercive or punitive • Offering advice • A bag of tricks to apply to someone

Express Empathy

• Empathy is the foundation of MI where one works with an attitude of acceptance

• It is NOT the same as agreement or approval but rather where one has desire to understand another’s perspective

Support Self-Efficacy

• Self-efficacy is the belief in one’s ability to be competent in specific situations and tasks

• Behavior change occurs when a client deems the behavior important and feels about to make changes (Miller & Rollnick, 2002)

Roll with Resistance • Resistance is an interpersonal process and should be

met with clarification of the person’s point of view instead of correction (Miller & Rollnick, 2002)

• When sensing resistance of statements against change, stop drop and roll Stop – pause and consider why the client may not want to

change Drop – your current approach and try something else.

Are you arguing? Roll –with resistance, which means to expressing an

understanding of the person’s point of view while emphasizing personal choice

Develop Discrepancy

• Behavior change is more likely to occur when the new behavior is identified as being consistent with an individual’s goals and values.

• This is done by evoking, reflecting and magnifying the discrepancy between the person’s values and goals and their current behaviors

Phase 1 – Building Motivation to Change & Phase 2 – Strengthening Commitment to Change

Phase 1 – Building Motivation to Change • Phase 1 is about building intrinsic motivation to

change with the overall goal being to resolve ambivalence

• Primarily precontemplation and contemplation stages of change.

Four Client Profiles

Low Importance, Low Confidence

High Importance, Low Confidence High Importance, High Confidence

Low Importance, High Confidence

Miller, Rollnick

Neither see change as important nor believe they could succeed in making the change.

Willingness to change but low confidence in ability to make the change.

Confident they could make the change if they thought it were important to do so, but no persuaded to make the change.

Both see it as important to change and that they could succeed in doing so.

Change Talk

• Change talk is when we hear a client speak in a way that supports making a positive change. ▫ Whether a person will continue to explore change

talk or steer away from it depends on how we respond.

DARN • Desire: want, wish, like

I want to stop smoking I would like to follow my parent’s rules so they

wouldn’t nag. • Ability: can, could, able

I could cut back on smoking if I wanted to I might be able to stop drinking

(Naar King, 2011)

DARN • Reason: for change

I really don’t’ want to end up on dialysis If I get another dirty urine drug screen, they’ll kick

me out of this program • Need: have to, important

I need to lose some weight I’ve got to get my grades up to graduate

(Naar King, 2011)

What to do with Change Talk….

Phase 1 Techniques • OARS

▫ Open-ended questions Allows the student to speak and give information

▫ Affirmation Positive statements of a client’s behavior that

deserve recognition. ▫ Reflective listening Repeating, rephrasing and/or paraphrasing, as well

as, reflecting on feeling statements ▫ Summarizing Offering a summary of the student’s statements to

ensure clarity and understanding

Phase 1 Techniques • Developing Discrepancy:

▫ How do you think your life would be different if you were not ____ (drinking, smoking, skipping your medication, getting stressed out, etc)?

▫ How do you imagine your life to be like if you don’t make changes and continue to ____ (use, cut class, not study, smoke, etc)?

▫ How does your _____ (risky behavior) fit in with your goals? ▫ On one hand, you say that your _____ are important to you, yet

you continue to _____. Help me to understand… ▫ What do you feel you need to change to achieve your goals? ▫ How will things be for you a year from now if you continue to

_____ (risk behavior))?

Phase 1 Techniques

• Decisional Matrix

Benefit of changing

Benefit of not changing

Cons of changing

Cons of not changing

Phase 1 Techniques

• Ruler ▫ Ruler (How important would you say it is for you

to ____? And how confident would you say you are that if you decided to ____ you could do it?

▫ Why are you a ___ and not lower? This elicits change talk!

Phase 2: Strengthening Commitment to Change • This phase is about strengthening the

commitment to change and developing a plan to actually accomplish it

• Primarily preparation, action and maintenance stages of change.

Phase 2 Techniques • Set a goal and change plan • Menu of options

▫ Offer options for the client on what their change plan can look like

• Short reflections ▫ Short reflection breaks can be used to maintain

rapport, let the patient know that you care what he or she thinks, and avoid information overdose. Techniques to use in such reflection breaks can be similar to the type of reflective listening

“I alone cannot change the world, but I can cast a stone across the waters to create

many ripples.” – Mother Teresa